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Towards a sociology of healthcare safety and quality
Davina Allen, Jeffrey Braithwaite, Jane Sandall and Justin Waring
Introduction
Improving the quality and safety of healthcare is a global priority (Braithwaite et al. 2015, WHO 2002). As healthcare organisations and systems across the developed and developing world face unprecedented financial constraints, growing demands for services (especially from ageing populations with long-term conditions and co-morbidities), and the challenge of keeping pace with technological progress, the case for a deeper understanding of these issues is particularly pressing. Hitherto, research and practice in quality and safety have been dominated by disciplines such as medical and safety science, social psychology, and human factors which have framed how quality and safety is understood, how it should be measured and studied, and the policies, interventions and practices through which it should be addressed. While quality and safety cuts across many traditional sociological concerns, and sociology has continued to progress understanding in this field, its insights and potential contribution have, until recently, been relatively neglected by mainstream policy and research. This might, in part, reflect a tension between the interventionist orientation of proponents of the dominant paradigm and the more critical detached stance of sociologists who, historically at least, have eschewed simplistic explanations or prescriptions for policy and practice. It may also arise from the complexities so often revealed by sociological research, rendering pressing clinical and organisational problems as less amenable to immediate solutions. After all sociologists have the reputation of Cassandra: when we make prophesies they are usually laden with doom and thus fated to be disregarded (Dingwall and Allen 2001). It is also the case that while sociologists have made, and continue to make, important contributions to the understanding of quality and safety, much of this work is fragmented across different sub-specialisms. As the introductory review chapter to this monograph shows (Waring et al. this volume), the insights of classic contributions by Strauss et al. (1985) on the social organisation of healthcare work, Illich (1976) on medical iatrogenesis, Bosk (1979) on managing medical mistakes, Timmermans and Berg (1997) on standardization, Fox (1999) on medical uncertainty and Rosenthal (1995) on the management of problematic doctors have largely been ignored within the prevailing orthodoxy. Within sociology itself, however, these earlier studies have provided the foundations for a new generation of sociological research oriented to this policy priority (for example, Dixon-Woods 2010, Jensen 2008, Mol 2008, Waring 2005). What has emerged from this growing corpus of work is a recognition that patient safety is not simply a matter of individual or group psychology or systems engineering, but is shaped by wider socio-cultural and political structures. A sociological perspective also reveals the hidden influence of inequalities of power (between occupations, within occupations and between patients and professionals) on quality and safety, how these problems might be managed and by whom, as well as the everyday – and often invisible – situated practices through which quality and safety are accomplished (Allen 2014, Iedema et al. 2006, Mackintosh and Sandall 2010, Macrae 2014, Mesman 2011).
If healthcare safety and quality are to be more thoroughly understood, their textured nature and multi-dimensional properties drawn out, and a more integrated and programmatic approach provided, it is important that such sociological insights are brought to the fore. The aim of the 22nd Sociology of Health & Illness Monograph is to further this aspiration by showcasing some exemplary studies. It offers a reflection on the contribution sociology can make and is making to the healthcare quality and safety agenda and raises some critical questions about the future of sociological engagement. How can we understand and explain the social, cultural and lived experiences of quality and safety? What theories, models and concepts are useful in progressing the quality and safety agenda? What is the appropriate balance between a sociology ‘of’ and a sociology ‘for’ quality and safety? What distinctly sociological research approaches might be applied to the study of quality and safety? What analytical perspectives might offer novel insights?
Parallel paths?
The first chapter in the collection reviews the emergence of this field and traces its evolution. Waring et al. argue that research and practice in quality and safety has progressed along two largely parallel paths. While an orthodox paradigm, dominated by those pursuing medical and safety science, has largely set the agenda in this field, the sociological paradigm has offered a more critical and nuanced understanding of these issues drawing on central disciplinary concerns such as: expertise and knowledge, the professions and healthcare division of labour, deviance and social control, risk, socio-technical innovation, governance and regulation, experiences of health and illness, organisational culture, help-seeking behaviour, professional-patient relationships, power and politics, and bureaucracies and institutions. There is now an accumulated body of sociological knowledge to provide the foundations for systematic engagement with dominant understandings of the problem of healthcare quality and safety and approaches to the management of risk and error and the chapters in this collection signal some fruitful directions of travel.
Organising for safety and quality
The first theme in the Monograph considers organising for quality and safety. Within the orthodox paradigm many see the solution to healthcare quality and safety in the restructuring and reorganisation of healthcare work (e.g. Chang et al. 2005, Donaldson 2009, Woloshynowych et al. 2005). This rationalist view is founded on the belief that organisational systems can be engineered and that revising formal structures and processes is the key to safer, more effective and efficient service delivery. From a sociological perspective, such assumptions are overly reductionist, and can often result in mechanistic interventions which have unintended negative consequences. For example, Braithwaite et al. (2006) found that restructuring large hospitals had deleterious effects – such as confusion and inefficiencies – rather than creating more streamlined systems, and Fulop et al. (2005) found that restructuring put people back at least eighteen months in terms of managerial and planning progress. Oxman (2005) and Braithwaite et al. (2005) went even further, and questioned the preoccupation with restructuring health systems activities, parodying the efficacy, the relevance and even the sanity of continually applying the structural ‘solution’ with no obvious benefits. Infante (2006), coming from a different angle, eschewed managerialist-oriented optimism about the possibility of organising for quality and safety, arguing against the very idea that systems are able simply to respond to some form of ‘rolled out’ improvement activities. For Infante, a ‘system’ is an abstraction, even a kind of mirage, and progress is infeasible without adequate theorisation at the centre of which lie relationships, power, culture and complexity. As a rich body of sociological research has shown, healthcare work is complex and its organisation challenging. There will always be a human spirit which wants to see complex problems addressed through the application of clear answers and solutions. Unfortunately, it is rare for the world to yield to this kind of simplification. Focusing on ‘the structure’ or ‘governance’ or ‘organisation’ in order to address quality and safety while important, represents a partial view. Politics, culture and relationships – all important constructs in making care safe and improving quality – are overlooked when excessive attention is placed on structural factors.
The governance and coordination of patient safety is thus a significant organisational challenge which remains theoretically and methodologically under-developed. The chapters in this section attempt to address this problem. Freeman et al. draw on observational data from four hospital Foundation Trusts to offer insights into the operation of hospital boards in the English NHS. Boards are responsible for ensuring the quality of care and safety of patients under their jurisdiction. Following Hajer and Versteeg (2005), Freeman et al. combine elements from the conceptual frameworks of dramaturgy (Goffman 1974) and performativity (Austin 1962) to explore the enacted dimensions of patient safety governance. The chapter is underpinned by the idea that ‘reality is mediated through the application of frames’, and examines the socio-cultural nature of patient safety as administered by Executive Boards, focusing in particular on the processing and interpretation of performance data. Despite the distance between them, Freeman et al. found an unexpected influence from the Executive Board at the ‘blunt end’ of the hospital on the clinical frontline. Executive Boards can set the scene and through their activities establish a tone for patient safety and quality across the organisation. The Boards in Freeman et al.'s study focused attention differently and through this, established different standards and priorities.
Shifting focus, Mackintosh and Sandall drill down into the world of seriously ill patients and through observations and staff interviews examine the frontline organisation of how patients are identified, rescued and resuscitated in medical and maternity settings. Applying Strauss et al.'s (1985) classic patient trajectory concept they examine patients’ journeys to show how ‘rescue work’ differed across the two contexts. In maternity services, patients were typically healthy and adverse events few, staff were alert to crises and they mobilised their capacity to be responsive when necessary. In contrast, in the medical wards where patients were older, more infirm and longer-term, it was accepted that rescue was necessary but that sometimes patients would die. The structures and organisational arrangements in these study sites were poorly des...
